Application For Employment
As an Equal Opportunity Employer, USPI prohibits
discrimination in employment on the basis of race,
color, religion, national origin, gender, disability or age. 15305 Dallas Parkway, Ste. 1600
Addison, Texas 75001
Phone: (972) 713-3500
PERSONAL INFORMATION
Print or Type clearly and neatly.
LAST NAME FIRST NAME MIDDLE PREFERRED NAME SOCIAL SECURITY NUMBER
NAME
MAILING ADDRESS HOME PHONE
CITY STATE ZIP CODE EMAIL ADDRESS ALTERNATE PHONE
HOW LONG HAVE YOU LIVED AT THIS ADDRESS?
WHO MAY WE CONTACT IN CASE OF AN EMERGENCY? Telephone Number:
POSITION INFORMATION
Candidates may apply for one position per application.
POSITION TITLE JOB NO./LOCATION SEEKING
Harvard Park Full-Time Part-Time PRN/Supplemental
Surgery Center
TOTAL YEARS OF EXPERIENCE IN POSITION APPLYING FOR: SHIFT AVAILABILITY
Day Evenings Rotating Schd Any
TARGET SALARY TARGET START DATE WEEKEND AVAILABILITY
Every Weekend Alter. Weekends No Weekends
HAVE YOU EVER APPLIED FOR EMPLOYMENT AT USPI BEFORE? When Disposition
EDUCATION and TRAINING
Graduation Date Name of Institution and Location Degree/Program
HIGH SCHOOL
COLLEGE/UNIVERSITY
COLLEGE/UNIVERSITY
GRADUATE SCHOOL
TRADE SCHOOL
LIST ANY SPECIAL SKILLS WHICH YOU ARE QUALIFIED AND EXPERIENCED (e.g. Typing, Software, Etc.)
PROFESSIONAL CREDENTIAL(S)/AFFILIATION(S)
CERTIFICATION/LICENSURE ACCREDITING ORGANIZATION EXPIRATION DATE PROFESSIONAL MEMBERSHIP
Has your license (in any jurisdiction that you may have been licensed in) ever been investigated, suspended or revoked?
If yes, please detail the circumstances and the final outcome: (An affirmative answer will not disqualify you from being considered as a candidate for
employment).
Fax completed application to (303) 765-3595
USPI FORM
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HEALTH CARE SPECIALTY
AREA YEARS EXPERIENCE
AREA YEARS EXPERIENCE
AREA YEARS EXPERIENCE
AREA YEARS EXPERIENCE
AREA YEARS EXPERIENCE
PLEASE INDICATE WHICH OF THE FOLLOWING CREDENTIALS YOU CURRENTLY HOLD
CPR Exp. Date OCN Exp. Date
ACLS Exp. Date CNOR Exp. Date
PALS Exp. Date CRRN Exp. Date
NALS Exp. Date CCRN Exp. Date
CEN Exp. Date EKG Course Completion Date
Other Exp. Date Critical Care Course Completion Date
IV Therapy Course Completion Date Other Courses Completion Date
LIST ANY OTHER EDUCATION TRAINING, SPECIAL SKILLS or CERTIFICATES/LICENSES THAT YOU POSSESS THAT ARE RELATED TO THIS JOB.
GENERAL INFORMATION
LIST ANY FOREIGN LANGUAGES THAT YOU FLUENTLY SPEAK. READ WRITE SPEAK
MILITARY EXPERIENCE? If, YES, what branch? Rank:
FROM___________________ to _________________ LIST DUTIES IN SERVICE
CAN YOU, UPON EMPLOYMENT, SUBMIT VERIFICATION OF YOUR LEGAL RIGHT TO WORK PERMANENTLY IN THE UNITED STATES?
ARE YOU 16 YEARS OLD OR OVER? IF UNDER 18, STATE AGE:
HAVE YOU EVER BEEN CONVICTED OF A FELONY, OR PLEADED NO CONTEST TO A FELONY, OR BEEN CONVICTED OF A MISDEMEANOR RESULTING IN
IMPRISONMENT OR A FINE OVER $500 DURING THE LAST TEN YEARS? (Criminal convictions are not an automatic bar to employment but will only be considered in relation
to specific job requirements.) IF YES, PLEASE EXPLAIN.
CAN YOU PERFORM THE ESSENTIAL FUNCTIONS OF THIS POTENTIAL JOB?
DO YOU REQUIRE ANY ACCOMMODATION TO PERFORM THE ESSENTIAL FUNCTIONS OF THIS JOB?
IF YES, PLEASE EXPLAIN.
IF YOU ARE PRESENTLY EMPLOYED, MAY WE CONTACT YOUR EMPLOYER?
HAVE YOU EVER PREVIOUSLY BEEN EMPLOYED BY USPI OR ANY OF ITS AFFILIATED COMPANIES?
IF YES, WHAT WERE YOUR DATES OF EMPLOYMENT?
IF YES, WHAT WAS THE NAME OF THE FACILITY?
IF YES, WHAT WAS YOUR NAME WHEN YOU WERE PREVIOUSLY EMPLOYED?
ARE YOU CURRENTLY OR HAVE YOU PREVIOUSLY BEEN EXCLUDED, SUSPENDED, OR OTHERWISE BEEN INELIGIBLE FOR PARTICIPATION IN FEDERAL
PROGRAMS, OR DO YOU HAVE A CONTROLLING INTEREST IN AN ENTITY THAT HAS BEEN SO EXCLUDED OR SUSPENDED? HAVE YOU EVER BEEN
SANCTIONED, DISCIPLINED, DEBARRED, AND/OR EXCLUDED BY A DULY AUTHORIZED AGENCY, OR ARE THERE CURRENT RESTRICTIONS/LIMITS ON YOUR
LICENSE OR CERTIFICATION?
IF YES, PLEASE EXPLAIN.
HAVE YOU HELD JOBS IN THE PAST TEN YEARS OTHER THAN THOSE LISTED ON THIS APPLICATION?
HAVE YOU EVER BEEN TERMINATED FROM A JOB OR RESIGNED FROM A JOB AS AN ALTERNATIVE TO TERMINATION?
HAVE YOU EVER BEEN DISCIPLINED OR WARNED BY AN EMPLOYER FOR EXCESSIVE ABSENCE, LATENESS, OR POOR JOB PERFORMANCE?
IF YES, WHICH ONE?
ARE YOU PRESENTLY UNDER AN EMPLOYMENT CONTRACT? IF YES, WHEN DOES IT EXPIRE?
DO YOU CURRENTLY HAVE ANY RELATIVE(S), OR PERSONS WITH WHOM YOU ARE INVOLVED IN A CLOSE PERSONAL RELATIONSHIP, EMPLOYED BY USPI?
IF YES, LIST:
USPI FORM
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EMPLOYMENT HISTORY
List all positions held in the past ten years, beginning with most recent employment.
NAME OF COMPANY/ORGANIZATION TYPE OF COMPANY/BUSINESS/INDUSTRY CITY/STATE
START DATE END DATE JOB TITLE REASON FOR LEAVING
STARTING SALARY FINAL SALARY YOUR NAME WHEN EMPLOYED SUPERVISOR NAME SUPERVISOR TELEPHONE
NAME OF COMPANY/ORGANIZATION TYPE OF COMPANY/BUSINESS/INDUSTRY CITY/STATE
START DATE END DATE JOB TITLE REASON FOR LEAVING
STARTING SALARY FINAL SALARY YOUR NAME WHEN EMPLOYED SUPERVISOR NAME SUPERVISOR TELEPHONE
NAME OF COMPANY/ORGANIZATION TYPE OF COMPANY/BUSINESS/INDUSTRY CITY/STATE
START DATE END DATE JOB TITLE REASON FOR LEAVING
STARTING SALARY FINAL SALARY YOUR NAME WHEN EMPLOYED SUPERVISOR NAME SUPERVISOR TELEPHONE
NAME OF COMPANY/ORGANIZATION TYPE OF COMPANY/BUSINESS/INDUSTRY CITY/STATE
START DATE END DATE JOB TITLE REASON FOR LEAVING
STARTING SALARY FINAL SALARY YOUR NAME WHEN EMPLOYED SUPERVISOR NAME SUPERVISOR TELEPHONE
NAME OF COMPANY/ORGANIZATION TYPE OF COMPANY/BUSINESS/INDUSTRY CITY/STATE
START DATE END DATE JOB TITLE REASON FOR LEAVING
STARTING SALARY FINAL SALARY YOUR NAME WHEN EMPLOYED SUPERVISOR NAME SUPERVISOR TELEPHONE
Please give explanation of any lapses in employment dates above:
USPI FORM
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PROFESSIONAL REFERENCES
List three individuals - minimum of two (2) supervisory references.
NAME AND ADDRESS OCCUPATION PHONE
1
2
3
Please include any other information you think would be helpful to us in considering you for employment, such as additional work experience, articles/books published, activities,
honors received, etc. (You may omit all information that would indicate age, sex, race, religion, color, national origin or handicap).
AGREEMENT
PLEASE READ THE FOLLOWING CAREFULLY.
By signing below, I certify that the information I have provided on this application is true and correct to the best of my
knowledge, and I understand that any misrepresentation or willful omission of facts shall be cause for rejection of this
application or termination. I also certify that I have read, understand, and authorize any person, agency, or other entity
contacted by USPI or its agents to furnish the information listed below.
I hereby authorize USPI to conduct work history, education, personal reference or police record inquiries to determine my
acceptability for employment. I authorize USPI and its agents to procure a consumer report and/or investigate consumer
report about my background, character or reputation, including but not limited to information as to my employment,
education, consumer credit history (if appropriate for certain job descriptions), driving record, social security number
verification, criminal record, and/or other public record history. I authorize all persons to fully disclose information relevant
to this investigation. I release from liability all persons, companies, and government or other agencies disclosing such
information. If further authorize a photocopy of this authorization to be considered an original.
I understand that this employer agrees that it will provide workers' compensation insurance coverage for its employees. In
the event of an injury in the workplace, I agree that my sole remedy lies in coverage under this employer's workers'
compensation insurance policy.
I understand, and agree that as a condition of employment, I will be required to submit to an employment physical
examination and a drug screen, and other physical examinations consistent with law during my employment at USPI. I
may, at the discretion of USPI be required to submit to a drug screen upon request during my employment. I further agree,
if employed, to observe all rules, regulations and policies of USPI and participate in USPI's EDGE program, which focuses
on providing excellence to its patients and surgeons. Additionally, I comprehend USPI's commitment to its Code of
Conduct, Compliance Plan and anti-harassment policies and further agree, if employed, to carefully review and abide by
these policies. If I am employed at USPI, I understand that my employment can be terminated without cause and without
notice, at any time, at the option of USPI.
APPLICANT SIGNATURE: DATE:
REFERRAL SOURCE
INDICATE SPECIFICALLY HOW YOU HEARD ABOUT POSITION OPENINGS WITH USPI.
Rehire: Internet: UnitedSurgical.com: Referral: Other:
FOR INTERNAL PURPOSES ONLY
Application Received By Application Forward To Date Forwarded Comments
USPI FORM
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